SMILE, PRK or ICL in Seattle: Alternatives to LASIK Compared

Why LASIK might be off the table

The AAO says LASIK candidates need healthy corneas that are thick enough and a prescription that hasn't changed much in a year, and that severe dry eye or a history of certain eye infections can rule you out. LASIK also can't correct presbyopia (AAO). FDA-approved labeling for one laser adds that LASIK may make dry eye worse (FDA).

The alternatives below aren't automatically safer or better. Each has its own candidacy rules and risks, and only a surgeon who has measured your eyes can say whether any of them fits. If you haven't read it yet, our LASIK guide covers the FDA's full list of reasons LASIK may not be for you.

SMILE and other lenticule procedures

The AAO calls SMILE (small incision lenticule extraction) a newer type of laser refractive surgery. The laser creates a disc of tissue, called a lenticule, which is removed through a small incision (AAO).

Cleveland Clinic says SMILE treats nearsightedness and astigmatism through an incision under 4 mm, needs no stitches, and heals in about one to two days (Cleveland Clinic).

SMILE is one brand in a family of lenticule-extraction procedures. EyeWiki says SMILE, from Zeiss, was the first commercially available one, and lists SILK (Johnson & Johnson), SmartSight (SCHWIND) and CLEAR (Ziemer) as the others (EyeWiki_Surgeries)). If a Seattle practice offers this type of surgery, ask which platform it uses.

Who may not be a SMILE candidate

The AAO says candidates need a prescription that hasn't changed in a year and healthy corneas. It lists people who may not be candidates, including those with:

• Corneal abrasions or corneal disease
• Advanced glaucoma
• A cataract that affects vision
• Uncontrolled diabetes

The risks the AAO lists include infection and blindness.

SMILE and LASIK: one recent comparison

At the AAO's 129th annual meeting, a 60-patient study treated one eye with wavelight plus LASIK and the other with SMILE Pro. Every wavelight plus eye ended within a quarter-diopter of its target, compared with about three-quarters of SMILE Pro eyes (AAO). It's one study of specific devices, so ask any surgeon which platform they use and what their own results look like.

PRK

The AAO describes PRK (photorefractive keratectomy) as a laser refractive surgery that usually takes about 15 minutes. The cornea's outer layer may be removed with a brush before the laser reshapes the cornea (AAO). Cleveland Clinic says PRK treats nearsightedness, farsightedness and astigmatism, and can create monovision for presbyopia (Cleveland Clinic).

We didn't find a sourced recovery timeline for PRK in our research, so we don't give one. Ask the surgeon to put the expected recovery, time off work and when you can drive in writing.

Phakic IOLs, including the ICL

Phakic intraocular lenses are lens implants rather than corneal surgery. The FDA describes them as thin lenses implanted permanently to correct nearsightedness (FDA). The AAO says they are for high prescriptions that can't be safely corrected with corneal surgery, and that they go in front of or behind the iris (AAO).

In a February 2017 AAO article, a surgeon described the procedure as more invasive than laser surgery, with higher risk. The same article reported a study that found phakic IOLs safe and effective after five years (AAO).

STAAR Surgical's Visian ICL received FDA approval for nearsightedness in adults, and STAAR said it had been implanted in more than 40,000 eyes worldwide (Healio). The FDA later approved the EVO and EVO+ Visian ICL for nearsightedness with or without astigmatism. According to Optometry Times, the approval covers:

• Adults aged 21 to 45
• An anterior chamber depth of at least 3.00 mm
• A prescription that has been stable within 0.5 diopter for one year
• Nearsightedness with or without astigmatism

Optometry Times also notes that the lens can be removed by a physician.

Refractive lens exchange

Refractive lens exchange (RLE), also called clear lens extraction, replaces your eye's natural lens with an artificial one. The AAO says it is done much like cataract surgery and may use multifocal or accommodative IOLs (AAO). Because it uses the same kinds of lenses, our cataract surgery guide explains the lens types in more detail.

The options side by side

What about cost?

We couldn't find sourced Seattle prices for SMILE, PRK, ICL or lens exchange, and the national figures we found cover LASIK only (see the LASIK guide). The FDA notes that most medical insurance won't pay for LASIK; check your own plan for any alternative. When you compare quotes, ask whether the price is per eye or for both eyes, which follow-up visits are included, and what happens if a second procedure is needed.

Questions to bring to your consultation

• What exactly ruled out LASIK for me, and can I see the measurements?
• Which alternative would you choose for me, and why that one rather than the others?
• Which laser platform or lens will you use, and what is it approved for?
• How many of these procedures do you perform?
• What will recovery look like, and when can I drive and go back to work?
• Who do I call if something feels wrong after hours?

Before the consultation, run the free license and board certification checks in our surgeon check guide.